Note

1. Note

2. Lecture 8c 24 February 2014 Renal continued

3. Renal Disease Acute Renal Failure Sudden loss of kidney’s ability to function -leads to a loss of ? Occurs due to heart failure or shock or urinary tract obstructions

4. Renal Disease Acute Renal Failure Consequences Decreased glomerular filtration rate which upsets fluid, electrolyte and acid base balances in the body AND increases blood urea nitrogen, blood creatinine and blood uric acid

5. Renal Disease  Acute Renal Failure Blood electrolyte levels rise when protein is catabolised for energy resulting in increased blood levels of potassium- why? Increased potassium levels in blood affect heart rate and can lead to heart failure-why?

6. Renal Disease  Acute Renal Failure Treatment -Dialysis -Nutrition Energy -too little energy leads to protein breakdown and that leads to blood urea and potassium up -give 25-35 kcal/kg body weight/day to start then adjustments to ensure adequate energy intake to avoid protein catabolism

7. Renal Disease Acute Renal Failure -Nutrition Treatment  Protein -better to give extra protein to address wound healing, infections, muscle wasting and negative nitrogen balance and dialyse the overload -0.8 to 1.2 g of protein /kg body weight per day no dialysis -1.2-1.5 g of protein /kg body weight per day if kidney function improves or if on dialysis

8. Renal Disease  Acute Renal Failure-Treatment Nutrition Fluids -over- or under-hydrated must be addressed – give urine output volume plus 500 ml for water lost though skin, lungs, and perspiration (if have vomiting diarrhea, or fever add more than 500 ml) to ensure correct fluid balance

9. Renal Disease •  Acute Renal Failure • Treatment  • Nutrition • Sodium • -restrict sodium to 2-3 grams per day -oliguric patients (reduced urinary output) may experience diuresis at the beginning of the recovery period and may need electrolyte replacement to compensate for electrolyte losses due to diuresis) • -diuresis-increased urinary output

10. Renal Disease  Acute Renal Failure Treatment  Nutrition Potassium 2-3 grams per day-generally speaking Phosphorous- restrict in diet if hyperphosphatemia

11. Renal Disease Acute Renal Failure Nutrition Treatment Need enteral or parenteral nutrition required if oral feeding does not provide sufficient energy-otherwise get protein catabolism that the kidney cannot process (ie get rid of protein metabolites) Enteral-enteral feeding (feeding tube) -protein and electrolyte restricted, with more kcal compared to standard formulas Total parenteral nutrition-only if patients severely malnourished or cannot consume food or tolerate food tube feedings for more that 14 days

12. Chronic renal failure Causes Include blood lipids, diabetes, hypertension

13. Chronic renal failure Treatment Energy -too little energy leads to protein breakdown -blood urea and potassium up -30-35 kcal/kg body weight/day -less on peritoneal dialysis due to glucose load in dialysing solution -table 28-5 Rolfes et al

14. Chronic renal failure Treatment Protein -as loss of renal function progresses -50%(at least) of protein intake should be from high quality protein sources(eggs, milk products, meat, poultry, fish, soybeans)-explanation-why? -once dialysis begins- can relax protein restrictions as protein metabolites are removed from the body by dialysis

15. Chronic renal failure Nutrition Treatment Lipid and carbohydrate -restrict saturated fat, trans fat and cholesterol -complex carbohydrates may minimise elevated glucose and triglycerides -peritoneal dialysis (with dextrose as the hyperosmotic agent)- restrict dietary simple carbohydrates-why?

16. Chronic renal failure Treatment Sodium and Fluids -restrict as loss of renal function progresses (fluids restricted only as urinary output drops) -sodium and fluid restrictions prevents edema, hypertension and heart failure -needs governed by person’s weight, blood pressure, urinary output and electrolyte levels

17. Chronic renal failure Treatment Potassium -individualised according to serum values for pre-dialysis, 2-3 grammes on hemodialysis, and 3-4 grammes on peritoneal dialysis -table 28-5 Rolfes et al

18. Chronic renal failure Treatment Phosphorous -restrict as renal failure progresses -increased blood phosphate happens here and causes decreased active vitamin D and hence decreased calcium absorption -milk products, peanut butter, sardines and legumes are high in phosphorous

19. Chronic renal failure Treatment Vitamins -increase B6 and folate –these are reduced by restrictive diets, dialysis, and drug therapy -restrict supplemental vitamin C to 100 mg/day max due to kidney stones issue Iron supplements -required for hemoglobin synthesis- hemodialysis